Palms Retirement Center

Allegation investigated: Staff do not ensure that resident is provided an itemized monthly statement. Staff are not according privacy to resident in care. Staff do not ensure that resident's personal belongings are safeguarded

On 07/28/2026, Licensing Program Analyst (LPA) Mikkelson contacted the licensee via email to deliver final findings regarding a complaint that was received on 12/05/2023. **Continued on 9099-C page Unsubstantiated Staff do not ensure that resident is provided an itemized monthly statement. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not according privacy to resident in care. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff do not ensure that resident's personal belongings are safeguarded Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20231205145309

Allegation investigated: Resident eloped from the facility because staff did not provide adequate supervision Illegal Eviction

On 07/28/2026, Licensing Program Analyst (LPA) Mikkelson contacted the licensee via email to deliver final findings regarding a complaint that was received on 10/09/2023. **Continued on 9099-C page Unsubstantiated Resident eloped from the facility because staff did not provide adequate supervision Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Illegal Eviction Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20231009110307

Allegation investigated: Staff are refusing to provide resident with meals

On 07/28/2026, Licensing Program Analyst (LPA) Mikkelson contacted the licensee via email to deliver final findings regarding a complaint that was received on 08/02/2023. **Continued on 9099-C page Unsubstantiated Staff are refusing to provide resident with meals Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20230802135409

Allegation investigated: Staff administered a resident's medication incorrectly Staff did not ensure resident was properly secured while using a wheelchair resulting in multiple falls

On 07/28/2026, Licensing Program Analyst (LPA) Mikkelson contacted the licensee via email to deliver final findings regarding a complaint that was received on 08/18/2022. ** Continued on 9099- C page Unsubstantiated Staff administered a resident's medication incorrectly Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not ensure resident was properly secured while using a wheelchair resulting in multiple falls Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20220818152123

Allegation investigated: Staff denied resident from receiving medical care Staff denied giving resident medication Staff denied resident a phone call Staff denied residents rights to choose a roommate

On 07/28/2026, Licensing Program Analyst (LPA) Mikkelson contacted the licensee via email to deliver final findings regarding a complaint that was received on 03/08/2022. ** Continued on 9099- C page Unsubstantiated Staff denied resident from receiving medical care Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff denied giving resident medication Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff denied resident a phone call Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff denied residents rights to choose a roommate Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20220308100503

Allegation investigated: Facility is not isolating COVID positive residents. Facility does not have an adequate amount of PPE.

Licensing Program Analyst (LPA) Jenifer Tirre, met with Administrator Didimay Dimacali for the purpose of delivering findings for the above allegations. The investigation consisted of observations, records reviewed and interviews conducted. On August 29, 2023, the department received allegations that Facility is not isolating COVID positive residents and Facility does not have an adequate amount of PPE. The investigation was completed by the department and revealed the following: Regarding Facility is not isolating COVID positive residents Per observations residents were relaxing in common areas and spread apart throughout common areas. Residents who tested positive had signs posted on room doors notifying visitors. Per record review, Department provided a Covid log of residents who were positive. Covid log showed several sets of roommates who were isolating together as well as individual residents in private rooms. Log provided onset of positives as well as symptoms. Per facility Infection Control Plan dated May 25, 2022, stated facility to contact Infection Preventionist, remind residents of proper hand hygiene, and additional cleaning and disinfection activities to be completed by staff in common areas. CONTINUED ON 9099C Unsubstantiated Plan also states that separation and quarantine would be provided in cases needed. Per Staff interviews, staff stated residents were being monitored and given face masks. Staff stated they encouraged residents to stay isolated in rooms and that meals would be delivered to rooms. Staff mentioned that if positive residents needed to go out of facility for appointments, residents were reminded to wear masks when in public. Regarding Facility does not have an adequate amount of PPE: Per observations, the Department observed facility has supply closet with Personal Protective Equipment (PPE) such as boxes upon boxes of Vinyl Gloves, Face Masks, and N-95 Face masks. Facility has extra additional sheets and bedding available. Department also observed hand sanitizing stations placed through out facility hallways and in common areas available to residents, staff and visitors. Per record review Department obtained copies of PPE invoices and packing slips for purchased PPE supply. Per interviews, Staff stated that PPE Supplies were available and that masks were provided to residents during the time of initial complaint. Based on information provided from investigation, the allegations Facility is not isolating COVID positive residents and Facility does not have an adequate amount of PPE was deemed UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur as reported. An exit interview was conducted with Administrator Didimay Dimacali and copy of report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 22-AS-20230829083600

Allegation investigated: Resident sustained rash while in care Facility not safe guarding residents clothes

Licensing Program Analyst (LPA) Jenifer Tirre, met with Administrator Didimay Dimacali for the purpose of delivering findings for the above allegations. The investigation consisted of observations, records reviewed and interviews conducted. On July 27, 2023, the department received allegations that Facility Resident sustained rash while in care and Facility not safe guarding residents clothes. The investigation was completed by the department and revealed the following: Regarding Facility resident sustained a rash while in care, It was reported to Department that resident had a rash that spread on Residents body. Per observations, resident was observed with redness on arms. Department observed (R1) was gently scratching at arms which were lightly wrapped up with a sleeve so that R1 would not pick at skin. Per records reviewed R1 Physician’s report dated February 28, 2023, stated R1 did not have a history of skin breakdown. Shower Skin Assessment dated March 3, 2023, stated that R1 was noted to have red areas and unusual marks. Assessment noted that R1 had three red spots on right lower arm and two marks on knees. CONTINUED ON 9099C Unsubstantiated Facility Charting notes dated 7/25/2023 to 7/27/2023 state that R1’s family would have to work on dermatology appointments due to dermatology not being covered under Hospice care. Notes from 7/27/2023, states Hospice requested for inspection of R1’s room to which Facility conducted an inspection to which no signs of bed bugs or scabies were found in surrounding furniture inside room. Charting notes also state that R1’s Doctor will be contacted regarding medication for resident’s itching. On 7/27/2023, notes state that R1’s laundry soap was changed out due to possibility of causing skin irritation. Per interviews conducted, Witness interviews stated that R1 had a rash on arms that caused itching. Witness interviews stated that R1’s was believed to have a residual rash of dermatitis. Per staff interviews, staff stated that once notified of rash, facility had maintenance come out and perform inspection for bed bugs and scabies to which none were found. Staff interviews stated that facility switched out mattress, cleaned sheets as well as switched laundry detergents. Staff stated that they were looking to what could be root cause of rash and stated that R1 was the only resident who had rash, no other residents had a rash at time of initial complaint. Regarding Facility not safe guarding residents clothes, Per observations, LPA toured residents room where clothes and personal belongings were observed inside drawers. Per record review, R1 had a personal property and valuables list where 14 items were noted from clothing, shoes, hats, watch and glasses. Per interviews with staff, staff state that upon admission to facility Residents are to mark clothing with a marker with their name to differentiate residents clothes. Staff also mentioned that after clothing is washed staff take clothing to residents room once completed. Staff mentioned that in Memory Care section, that staff are monitoring residents and stated that on rare occasions they will see residents wander into other residents room to which staff will redirect. Staff stated they aren’t aware of clothing being stolen or other residents wearing other residents clothing. Based on information provided from investigation, the allegations Facility resident sustained a rash while in care and facility not safe guarding residents clothing was deemed UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur as reported. An exit interview was conducted with Administrator Didimay Dimacali and copy of report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 22-AS-20230727154102

Allegation investigated: Staff neglected resident resulting in severe dehydration and hospitalization Staff did not address resident's change in condition

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Maria Dimacali and the Director of Operations Eric Vaca and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed the staff, witnesses and reviewed records, and reviewed voicemails messages, and reviewed documents including, resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated June 2, 2022, R1’s preplacement appraisal dated May 31, 2022, elopement risk assessment dated May 15, 2022, R1’s functional capabilities assessment, R1’s Appraisal/Needs and Services Plan dated May 16, 2025, R1’s Admission Agreement dated May 13, 2025, R1’s consent for emergency medical treatment dated May 13, 2025, R1’s care notes for May and June 2025, R1’s physician’s report dated May 7, 2025, R1’s resident appraisal dated May 12, 2025, and St. Jude Medical Records for R1 dated July 7, 2025 to July 21, 2025. Unsubstantiated The investigation into the allegation, staff neglected resident resulting in severe dehydration and hospitalization, revealed the following. It was reported that R1 was hospitalized on August 27, 2025, due to dehydration and a urinary tract infection (UTI) and subsequently sent to a Skilled Nursing Facility (SNF) because the facility failed to ensure R1 was properly fed and hydrated. A review of records shows that R1 moved to the facility on July 9, 2015. R1’s physician report dated September 12, 2024, shows R1 has been diagnosed with Parkinson’s Disease, Epilepsy, Hypothyroidism and Hypertension. R1 is able to leave the facility unassisted and handle their own cash resources. R1 is not conserved, has no power of attorney and makes all their own decisions. On August 27, 2025, staff noted R1 to be lethargic. Staff assessed R1 and decided to call 911. R1 was transported to the hospital and admitted for Acute cystitis without hematuria (UTI). R1 was at the hospital from August 27, 2025, to September 5, 2025. Hospital records dated August 27, 2025, to September 5, 2025, show R1 could be argumentative to staff and refused medication on August 28, 2025. Hospital notes for September 2, 2025, state patient (R1) has not been eating well, refusing most meals, does take medication. Hospital discharge paperwork for R1 shows R1 did not have adequate intake of food and water but does not meet the criteria for moderate or severe malnutrition. The recommendation is for R1 to drink Ensure Plus High Protein daily with meals and the goal is to eat 70% of all of their meals and snacks. R1 was discharged to a Skilled Nursing Facility (SNF) on September 5, 2025. R1 was at the SNF until October 1, 2025, when they returned to the facility. A review of records shows that R1 has refused food and water, and the facility documented those incidents. R1 did not eat or ate very little on August 5, 7, 10, 13 and 14, 2025. A review of records shows R1 was on home health visits from July 5, 2025, to October 24, 2025. The Home Health notes for August 27, 2025, state R1 has a poor appetite. The Administrator reported that after each incident R1’s primary care physician (PCP) and emergency contact were notified. R1’s emergency contact verified this report. R1 reported that they eat and drink when they feel like it and do not always eat three meals a day. R1 reported that they know how to get up and serve themselves water if need be. Staff reported that R1 was always encouraged to eat and drink and to let staff know if they needed anything. R1 verified this report. Based on the evidence gathered from interviews and a review of records, there is not enough evidence to prove that the staff failed to provide care or neglected R1, causing dehydration which resulted in hospitalization. Therefore, the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not address resident's change in condition, revealed the following. It was reported that prior to their hospitalization on August 27, 2025, R1 was not getting out of bed and lost 20 pounds from June 2025 to September 15, 2025. A review of records shows that according to R1’s physician report dated September 12, 2024, R1 weighed 195 pounds. R1 was weighed at the hospital when they were admitted on August 27, 2025, and at the time of their discharge to the Skilled Nursing Facility (SNF) on September 5, 2025. R1 weighed 149 pounds on both dates. No other documents gathered during the investigation listed R1’s weight. R1 lost 46 pounds from September 12, 2024, to September 5, 2025. That is an average of just under 4 pounds a month. It is unknown how much weight R1 lost from June 2025 to September 2025. A review of records shows that R1 has refused food and water, and the facility documented those incidents. R1 did not eat or ate very little on August 5, 7, 10, 13 and 14, 2025. A review of records shows R1 was on home health visits from July 5, 2025, to October 24, 2025. The Home Health notes for August 27, 2025, state R1 has a poor appetite. The Administrator reported that after each incident R1’s primary care physician (PCP) and emergency contact were notified. R1’s emergency contact verified this report. R1 reported that they eat and drink when they feel like it and do not always eat three meals a day. R1 reported that they know how to get up and serve themselves water if need be. Staff reported that R1 was always encouraged to eat and drink and to let staff know if they needed anything. R1 verified this report. No other issues were reported until R1 was observed to be lethargic on August 27, 2025. Staff called 911 and R1 was transported to the hospital and admitted for Acute cystitis without hematuria (UTI). R1 was at the hospital from August 27, 2025, to September 5, 2025, and then discharged to a SNF on September 5, 2025. R1 was at the SNF until October 1, 2025, when they returned to the facility. The Administrator reported that they were unaware of R1 not ambulating prior to their hospitalization in August 2025. 2 out of 2 staff interviewed reported that R1 was able to ambulate on their own prior to August 27, 2025. R1’s emergency contact reported they were notified when R1 was hospitalized. R1 reported that if they wanted to move around or stay in their room, they can do what suits them. None of the evidence gathered supports the allegation. Based on the evidence gathered through interviews and documents reviewed the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. The first property list/inventory is dated January 1, 2024, and the property sheet dated September 21, 2025, showing what items R1’s emergency contact removed from the facility to take to R1 who was in at SNF at the time. R1’s emergency contact removed from the facility 2 pants, 2 shirts and 1 sweater. R1’s emergency contact signed and dated the form and there was a photocopy of their ID with the form. R1’s original property inventory sheet lists the following, 2 walkers, clothes, 5 jackets, bra, 3 socks and jogging pants. Nothing else is listed. The form is dated January 1, 2024. Dentures, shoes, personal effects and toiletries were not listed on the property inventory list. During the initial 10-day visit on September 25, 2025, the Administrator showed R1’s personal belongings box, which included dentures in their case, various clothing items, toiletries and 2 pairs of shoes and R1’s 2 walkers which were in their room, to LPA Alejandre. LPA observed all of R1's property in a box at the facility. The Administrator reported that they showed R1’s emergency contact R1’s property and they chose to only take clothing items. R1’s emergency contact reported they only took the items R1 requested and don’t remember seeing the other items. The Administrator reported that R1's items are kept secured at the facility. Based on evidence gathered the allegation, is Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 22-AS-20250923153556

Allegation investigated: Facility does not have an adequate plan to address resident's medication needs Staff did not provide requested document to resident's doctor

On June 22, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegations listed above. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator Maria Dimacali was notified via telephone and later arrived to assist with the inspection. During the course of the investigation, LPA interviewed residents, interviewed staff, reviewed and obtained pertinent documents for this complaint such as resident medication records. Regarding the allegation, facility does not have an adequate plan to address resident's medication needs, the following has been concluded: It was alleged that the facility does not have an adequate plan to address Resident #1 (R1) medication needs. LPA conducted a file review for R1 including R1's active medication orders. LPA observed that R1 receives assistance from the facility with their medications and R1's medications include both routine and as needed medications. LPA reviewed the facility's personnel report and observed that the facility currently has seven staff employed who are able to assist resident's with their medication needs. CONTINUED ON LIC9099-C Unsubstantiated Based on a review of the personnel report, it appears that there is sufficient staff coverage to assist R1, and other residents, with their medication needs during all times of the day. LPA conducted an interview with R1. R1 denied any issues with his medication needs and denied any issues with requesting his as needed medications from staff. LPA conducted an additional five resident interviews. The five residents interviewed stated that they all receive assistance with their medications from the facility and they also denied any issues with their medication needs. LPA conducted four staff interviews. Four out of the four staff interviewed denied the allegation and reported that there is at least one staff on duty at all times during each day to assist residents with their medication needs. Regarding the allegation, staff did not provide requested document to resident's doctor, the following has been concluded: It was alleged that staff did not provide requested document to R1's doctor. LPA attempted to conduct an interview with R1's doctor, Witness #1 (W1). However, LPA was unable to make contact with W1 for an interview after multiple attempts. LPA conducted an interview with R1. R1 stated that he did not recall if staff provided him with a copy of his medication list to give to his doctor, W1. LPA conducted four staff interviews. Two staff were unable to provide any useful information for this allegation. However, the other two staff denied the allegation and stated that staff did provide R1's doctor with the document that they requested. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the two allegations above are deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Maria Dimacali and a copy of the report was provided at time of visit.the state’s words, verbatim · CDSS document, Jun 22, 2026 · control 22-AS-20260617130520

Allegation investigated: Staff are disclosing a resident's personal information Staff are mishandling a resident's medications Staff are interfering with a resident's medical decisions Staff are not affording a resident privacy Staff are stealing the resident's personal belongings Staff are not following a licensed physician's orders Staff are threatening a resident Staff are unlawfully evicting a resident Staff are falsifying and misplacing records of a resident Staff do not seek timely health and medical attention for a resident Staff are overcharging a resident Staff are not properly reporting incidents involving a resident Staff do not address a resident's change in medical condition Staff are not providing adequate food service to a resident

On 06/03/2026, Licensing Program Analyst (LPA) contacted the licensee via email to deliver final findings regarding a complaint that was received on 07/31/2024. **Continued on 9099-C page Unsubstantiated Staff are disclosing a resident's personal information Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are mishandling a resident's medications Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are interfering with a resident's medical decisions Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not affording a resident privacy Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are stealing the resident's personal belongings Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not following a licensed physician's orders Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are threatening a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are unlawfully evicting a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. **Continued on 9099-C2 page Staff are falsifying and misplacing records of a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff do not seek timely health and medical attention for a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are overcharging a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not properly reporting incidents involving a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff do not address a resident's change in medical condition Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not providing adequate food service to a resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 22-AS-20240731154451

Allegation investigated: Staff mismanaged resident toileting supplies Resident was left in soiled bedding for extended amount of time Staff handled resident roughly

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings. LPA Tirre was greeted and granted entry into the facility by staff and explained reason for visit. During course of investigation, LPA conducted interviews, reviewed records, toured facility and made visual observations. Department requested pertinent documentation such as Physician’s Report, Admission Agreement, Appraisal, Needs and Service plan, face sheet, staff roster and Resident Roster. The investigation conducted revealed the following: Staff mismanaged resident toileting supplies Per staff interviews, five of five staff stated that Resident 1 (R1) was on incontinent supplies and received supply from DME (Durable Medical Equipment) Provider monthly. Staff stated that R1’s supplies were covered through insurance. Staff stated that R1 likes to drink a lot of liquids and goes through incontinent supplies but has never ran out of supplies. Interview with witness stated they do not know anything regarding incontinence supplies. Interview with R1 stated that they ran out of supplies and were informed by staff to pee on bed. cont 9099c Unsubstantiated Per observation, during investigation visits, LPA observed resident had a supply of diapers and under pads piled high on side of television next to wall across from R1’s bed. LPA observed incontinent supplies throughout resident’s room. Resident was left in soiled bedding for extended amount of time Per staff interviews, five of five staff stated that they were not made aware of R1 being left in soiled bedding for period of time. Staff interviews stated that R1 did need assistance with toileting and would be changed 3 to 4 times a day as well as checked on every two hours. Per witness interview, witness is aware of R1 needing assistance but does not know how often it is given at facility. Per R1 interview, R1 stated that on one particular occasion a staff member made them pee inside diaper and was left in soiled diaper for two days. Per observations LPA observed R1 to be comfortable during visits and R1 stated that they were not having the soiled issues as before. Per records reviewed R1’s physicians reports dated 4/23/22, 6/21/24 & 3/5/26 stated that R1 needs assistance with bathing, dressing and toileting due to their physical condition. Needs and Service Plan dated 6/20/25 states that R1 is total assist with bathing, grooming, dressing and toileting. Staff handled Resident roughly Per interviews, five of five staff stated that R1 never mentioned to them about being handled roughly by staff at facility. One staff member stated they were aware that R1 always requested about being handled “gently” while staff were providing care. Interview with R1 stated that a Care giver whose first name was provided shoved R1 against bed roughly and was rude. Interview with witness stated that R1 denied the allegation regarding staff, stating that R1 claims they were never pushed by a staff member, there was no abuse happening and that they felt safe at facility. Per observations, staff member whom R1 mentioned was not available for interview on 8/15/22 and was informed Staff member no longer works at facility and left back in 2022. LPA did not observe staff member on roster on 3/25/26. Per information gathered from investigation, the allegations Staff mismanaged toileting supplies, Resident was left in soiled bedding for extending amount of time and staff handled resident roughly were deemed UNSUBSTANTIATED meaning that although the allegations may have happened or are valid, there is no preponderance of evidence to prove that the alleged violations occurred as reported. An exit interview was conducted with Administrator Kathleen Tamondong, copy of report was discussed and provided.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 22-AS-20220713090933

Allegation investigated: Resident sustained a fracture after an unwitnessed fall Staff are not properly supervising resident who may be a fall risk Staff did not seek timely medical attention for resident in care Staff are not properly reporting incidents to authorized representatives Staff are leaving resident in soiled clothing for an extended period of time

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Eric Vaca and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed the staff, witnesses and reviewed records, and reviewed voicemails messages, and reviewed documents including, resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated June 2, 2022, R1’s preplacement appraisal dated May 31, 2022, elopement risk assessment dated May 51, 2022, R1’s functional capabilities assessment, R1’s Appraisal/Needs and Services Plan dated May 16, 2025, R1’s Admission Agreement dated May 13, 2025, R1’s consent for emergency medical treatment dated May, 13, 2025, R1’s care notes for May and June 2025, R1’s physician’s report dated May 7, 2025, R1’s resident appraisal dated May 12, 2025, and St. Jude Medical Records for R1 dated July 7, 2025 to July 21, 2025. Unsubstantiated The investigation into the allegation, Staff are not properly reporting incidents to authorized representatives, revealed the following. It was reported that R1 sustained falls on June 9, 2025 and July 2, 2025 and R1's authorized representative/emergency contact was not notified. A review of records shows R1 sustained falls on June 21, 2025, and July 7, 2025. The Administrator reported there is no record of any falls for R1 on June 9 or July 2, 2025. R1 could not recall how many times or the dates of when they have suffered a fall. The Wellness Director reported that they have no record of falls for R1 on June 9 or July 2, 2025. 5 out of 5 staff members reported they are unaware of any falls for R1 on June 9 or July 2, 2025. R1's authorized representative/emergency contact reported that they were notified about the falls on June 21 and July 7, 2025. R1's authorized representative/emergency contact could provide any details about the falls reported to have taken place on June 9 or July 2, 2025. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff are leaving resident in soiled clothing for an extended period of time, revealed the following. It was reported that R1 was not properly assisted with incontinence issues and would be left in their soiled clothes for an hour before they were assisted and changed and this caused R1 to be hospitalized. No specific details were provided as to when or how many times this occurred. R1's physician reported that R1's hospitalization and diagnosis of Sepsis secondary to UTI could not be attributed to poor hygiene and was caused by their overall poor health. The Administrator and Wellness Director reported they were unaware of any issues assisting R1 with incontinence issues and have heard no reports of residents being left in soiled clothing. 5 out of 5 staff members reported that R1 was not neglected in any way, was never left in soiled clothing and they constantly checked on R1. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. The investigation into the allegation, staff are not properly supervising residents who may be a fall risk, revealed the following. It was reported that R1 was known to fall risk and the facility failed to properly monitor R1 which led to numerous falls. R1 moved into the facility on May 13, 2025. R1 was diagnosed with polyneuropathy, Type II Diabetes, Chronic Obtrusive Pulmonary Disease (COPD), obesity, heart failure and chronic pain. R1’s psychiatric diagnosis includes bipolar disorder, depression, anxiety and psychotic disorder. R1 can communicate, is alert and oriented to time and place but experiences episodes of confusion. R1 can communicate their needs effectively and could follow instructions. According to the facility staff and R1’s physician R1 is a fall risk. According to R1’s physician R1 could walk 6 to 8 feet independently but required an assistive device or staff support for any distance beyond that. R1 was placed in a room near the medical technician’s office so they could be closer to staff and easier to monitor. R1’s physician reported that R1’s ability to communicate their needs and follow instructions meant one on one care was not clinically necessary. R1 utilized a motorized wheelchair and required assistance when transferring, bathing, dressing and incontinence care. R1 sustained fall on June 21, 2025, and July 7, 2025. The fall in June did not result in any injuries. A review of records shows R1 was on hourly safety checks. The Administrator, Wellness Director and 5 staff members reported that all staff members follow R1’s care plan that calls for hourly checks and for staff to assist with transferring, bathing, dressing and incontinence care. 5 out of 5 staff members reported that R1 was not neglected in any way and staff constantly checked on R1. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. R1’s physician reported that in their years attending and examining residents at the facility they have never witnessed any staff neglect. A Licensed Clinical Social Worker who had previously worked with R1 reported that staff attended R1 frequently and they did not observe anything that caused concern. Based on the evidence gathered through document review and interviews, the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not seek timely medical attention for resident in care, revealed the following. It was reported that after R1 fell on July 7, 2025, staff did not seek timely medical attention for R1. R1 moved into the facility on May 13, 2025. R1 was diagnosed with polyneuropathy, Type II Diabetes, Chronic Obtrusive Pulmonary Disease (COPD), obesity, heart failure and chronic pain. R1’s psychiatric diagnosis includes bipolar disorder, depression, anxiety and psychotic disorder. R1 can communicate, is alert and oriented to time and place but experiences episodes of confusion. R1 can communicate their needs effectively and could follow instructions. According to the facility staff and R1’s physician R1 is a fall risk. According to R1’s physician R1 could walk 6 to 8 feet independently but required an assistive device or staff support for any distance beyond that. R1 was placed in a room near the medical technician’s office so they could be closer to staff and easier to monitor. R1’s physician reported that R1’s ability to communicate their needs and follow instructions meant one on one care was not clinically necessary. R1 utilized a motorized wheelchair and required assistance when transferring, bathing, dressing and incontinence care. On July 7, 2025, R1 was discovered by staff on the floor of their room at approximately 7:00 am to 7:30 am. According to the special incident report dated July 8, 2025, for the fall incident on July 7, 2025, R1 suffered an unwitnessed fall and was in pain and 911 was called. R1 did not recall the time of the fall but reported they were not close to the call button to call for assistance. Staff reported seeing R1 in their bed around 6:00 am. R1 reported that they were transferring from their bed to their wheelchair unassisted when they fell. R1 did not have an explanation as to what caused the fall. R1 did report that they suffered memory loss following the fall on July 7, 2025, but did not provide any additional details. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. It was reported that the only reason 911 was called was because of R1’s insistence. A voicemail was provided to support this claim. A review of the voicemail shows facility staff (S1) called R1’s responsible party informing them R1 was sent to the hospital because they had a fall and R1 wanted to be sent to the hospital. S1 no longer works for the facility and never responded to a request for an interview. A review of hospital records shows that R1 was admitted to the hospital at 8:10 am on July 7, 2025. A review of facility records shows that R1 requested and received hospital transport several times for various reasons between their move in date, May 13, 2025, and the incident on July 7, 2025. It is unclear who prompted the 911 call. R1 was transported to the hospital shortly after their fall, therefore the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, resident sustained a fracture after an unwitnessed fall, revealed the following. It was reported that a lack of care and supervision resulted in R1 sustaining a fall that caused a fracture. R1 moved into the facility on May 13, 2025. R1 was diagnosed with polyneuropathy, Type II Diabetes, Chronic Obtrusive Pulmonary Disease (COPD), obesity, heart failure and chronic pain. R1’s psychiatric diagnosis includes bipolar disorder, depression, anxiety and psychotic disorder. R1 can communicate, is alert and oriented to time and place but experiences episodes of confusion. R1 can communicate their needs effectively and could follow instructions. According to the facility staff and R1’s physician R1 is a fall risk. According to R1’s physician R1 could walk 6 to 8 feet independently but required an assistive device or staff support for any distance beyond that. R1 was placed in a room near the medical technician’s office so they could be closer to staff and easier to monitor. R1’s physician reported that R1’s ability to communicate their needs and follow instructions meant one on one care was not clinically necessary. R1 sustained fall on June 21, 2025, and July 7, 2025. The fall in June did not result in any injuries. A review of records shows R1 was on hourly safety checks. The Administrator, Wellness Director and 5 staff members interviewed reported that R1 was constantly checked and assisted throughout the day. On July 7, 2025, R1 was discovered by staff on the floor of their room from approximately 7:00 am to 7:30 am. R1 did not recall the time of the fall but reported they were not close to the call button to call for assistance. Staff reported seeing R1 in their bed around 6:00 am. R1 reported that they were transferring from their bed to their wheelchair unassisted when they fell. R1 did not have an explanation as to what caused the fall. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. Staff found R1 on the floor of their room and called 911. R1 was transported to the hospital. R1 was diagnosed with a closed fracture of the fourth lumbar vertebra and Sepsis secondary to UTI. R1 was at the hospital from July 7, 2025, to July 21, 2025. On July 21, 2025, R1 was transferred to a skilled nursing facility (SNF). Based on the evidence gathered from a review of records, interviews from 7 staff members, R1’s physician and clinical social worker, the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 22-AS-20250715104426

Allegation investigated: Resident was sexually assaulted by another resident. Staff not administering resident’s medication as prescribed.

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct an investigation into the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Kathleen Tamondong and discussed the purpose of the visit. The investigation into the two allegations listed above revealed the following: It was alleged that an unidentified resident (R1) was sexually assaulted by another resident, (R2), in the facility cafeteria. The incident was reported to have happened in February and April of 2025. LPA contacted ten former employees of which six former employees informed LPA that they did not observe a resident sexually assault another resident at the facility. LPA was unable to speak to four of the ten former employees. LPA interviewed five current staff of which all staff informed LPA that they have not seen a resident sexually assaulting another resident at the facility. LPA interviewed ten residents in care, and seven of ten residents informed LPA that they have not experienced or seen any sexual assaults at the facility. Seven of ten residents informed LPA that they feel safe living at the community. Continue on LIC9099C Unfounded Three of ten residents could not confirm or deny the allegation. LPA reviewed two resident files to try and identify R2. Upon review, LPA did not observe any incidents pertaining to sexual assault or a history of sexual abuse. It remains unclear as to R2’s identity. LPA reviewed staff files and 3 of 5 staff have updated training regarding resident abuse. 5 of 5 staff have signed abuse acknowledgement forms dated March 16, 2026. LPA contacted Fullerton Police Department to request potential police reports that could match the allegation under review. No reports provided were found to be pertaining to the complaint allegation. Regarding the facility allegation of staff not administering resident medications as prescribed revealed the following: LPA interviewed five current staff members of which four staff informed LPA that all medications are given as prescribed. The remaining staff interviewed does not handle the medications. In addition, two of ten former staff interviewed confirmed they gave all medications as prescribed. The remaining eight staff did not confirm or deny due to their position or not speaking to LPA. LPA interviewed residents in care regarding their medications, and seven of ten residents informed LPA that they get assistance with their medications and have no complaints. The remaining three residents were unable to confirm or deny the allegation. LPA reviewed eight resident medications and medication administration records and observed that all were being given as prescribed at the time of the investigation. LPA reviewed 5 staff training records on resident personal rights and observed them to be current. LPA reviewed three of five staff having medication technician certifications from Pharmacy vendors. The two remaining staff were observed to have medication training provided by the facility but do not perform medication technician duties. Based on the evidence gathered, the Department finds the allegation is unfounded. A finding that the complaint is unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 22-AS-20251103152234

Allegation investigated: Staff are not addressing scabies outbreak.

Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegation. LPA met with the Assistant Administrator Kathleen Tamondong and explained the purpose of the visit. During the investigation, LPA inspected the facility, interviewed staff and residents, and collected and reviewed documents including the medical records, progress notes, care plans, medication lists, physician’s reports, staff roster, and client roster. The investigation revealed the following: It was alleged that Staff are not addressing scabies outbreak. Resident 1 (R1) moved into the facility on July 2, 2025 and moved out on January 11, 2026. On November 21, 2025, R1 was sent to the hospital due to a rash. It was confirmed that R1 was diagnosed with scabies at the hospital on November 21, 2025. R1 was treated with Permethrin ointment and discharged back to the facility the same day. Continued on LIC9099-C. Substantiated Permethrin is a medication used to treat scabies. The physician’s orders from the hospital dated November 21, 2025, stated that the discharge instructions were to wash off the Permethrin ointment in 8 to 14 hours and reapplied in 7 days. LPA reviewed R1’s Medication Administration Record (MAR) for the month of November to January 2026 which shows prescribed Permethrin medication was not noted in the MAR and was not given to the resident. A review of incident report from the facility shows that there have been no reports of scabies in November 2025 received by our Department. Seven out of seven staff including the Administrator interviewed denied that there were scabies incident in the facility on November 2025. LPA made several attempts to contact R1's family member to interview but was unsuccessful. Based on evidence gathered through interviews and document review, the preponderance of evidence has been met, therefore, the above allegation is found to be Substantiated. Violations are being cited per Title 22 of California Code of Regulations. See LIC 9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Assistant Administrator and a copy of this report and the LIC9099-D, along with a copy of the Appeal Rights were left at the facility.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 22-AS-20260123164353

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 30, 2026

87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency [...]: (1) A written report shall be submitted to the licensing agency [...] of the occurrence of any of the events specified in (A) through (D) below. This report shall include the [...] nature of event; [...] findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by: Based on record reviews and interviews, the facility failed to report the scabies incident of R1, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 20, 2026

Plan of correction: Licensee agrees to submit a written statement of understanding after reviewing the Titte 22 Regulations under 87211 Reporting Requirements. In addition, proof of training to all the staff will be submitted by POC due date on how the facility will ensure that scabies incidents will be reported to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 30, 2026

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in[...] Health and Safety Code section 1569.2(c).[...] (c) "Care and supervision" means the facility assumes responsibility for[...]assistance of daily living [...] includes taking medications [...]. This requirement was not met as evidenced by: Based on record review and interviews, the facility failed to ensure R1's prescribed medication for scabies was given since it was noted in the facility MAR. Facility also denied having a scabies incident for R1. This poses a potential health and safety risk to residents in care if facility is unaware of the resident scabies conditions.the state’s words, verbatim · CDSS document, Apr 20, 2026

Plan of correction: Licensee agrees to submit a written statement of understanding after reviewing the Titte 22 Regulations under Basic Services 87464. In addition, proof of training to all the staff will be submitted by the POC due date on how the facility will assist with medication administration and personal care regarding any scabies incidents.

Allegation investigated: Staff made inappropriate comments towards resident. Facility not providing resident with requested documents. Staff not ensuring resident is bathed. Facility failed to administer medications as prescribed.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver complaint findings LPA Tirre was greeted and granted entry into the facility by staff and explained reason for visit with Administrator Khatera Bahadory During the course of investigation, LPA reviewed records and conducted interviews. Department requested pertinent documentation such as Physician’s Reports, Medication Administration record, Medication logs, Appraisals and Admission Agreement. The investigation conducted revealed the following: On November 2, 2022 the department received a complaint alleging Staff made inappropriate comments towards resident, Facility not providing resident with requested documents, Staff not ensuring resident is bathed and Facility failed to administer medications as prescribed. CONTINUED ON 9099C Unsubstantiated Regarding Allegation Staff made inappropriate comments towards resident, Interview with Resident 1 (R1) stated that a staff member who they preferred not to name, made the following inappropriate comment after a witnessed fall “ you’re old and don’t need your knee’s. You are going to die”. R1 stated staff member made them feel shun for the incident occurring. Interviews with staff revealed that 5 of 6 staff members were not aware of inappropriate comments made and stated that R1 did not express concerns regarding staff. Regarding Allegation Facility not providing resident with requested documents, Interview with R1 stated that they needed personal records for upcoming doctors appointment, however when asked what records they needed and if they received such records, R1 could not recall the records requested and whether they received documents. Interview with Staff 1 (S1), revealed that R1 requested a copy of their Admission Agreement and S1 stated they provided document to R1. Regarding Allegation Staff not ensuring resident is bathed, based on documents received, R1’s Physician reports dated 10/28/22 under capacity for self care stated that R1 needs assistance with bathing. R1’s Functional capability assessment dated 9/30/22 also states R1 needs help with bathing and showering. No shower logs provided for R1. Interview with R1 revealed that they often wait to be showered. Interviews with staff members revealed that 3 of 6 staff stated that R1 was on a showering schedule. Interviews with staff revealed that 3 of 6 staff stated R1 had showers as needed 3 to 7 days a week. Regarding Allegation Facility failed to administer medications as prescribed, Record review revealed that R1 was on two medications for pain management (Hydrocodone Acetaminophen and Tramadol HCI) both meds prescribed as take one pill every six hours as needed for pain. Resident also on Trazodone for Insomnia. Medication logs from 11/5/22-11/7/22 show R1 received Pain medication Tramadol 6x for pain. Facility nurse notes state on 11/11/22 Doctors office contacted facility that they were not going to refill Norco pain med due to resident being referred to pain management doctor & resident was informed. Interview with R1 stated that they were not receiving their Norco (Hydrocodone Acetaminophen) medication and instead was given “Trazodone”. Interview with Staff 2 revealed that R1 is given medications as prescribed. Interview with Staff 1 stated that R1 always wanted PRN pain meds immediately after making request and wanted additional dosage immediately after an hour. Based on information provided in investigation, the preponderance of evidence has not been met, deeming the allegations Staff made inappropriate comments towards resident, Facility not providing resident with requested documents, Staff not ensuring resident is bathed and Facility failed to administer medications as prescribed to be Unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred as reported. An exit interview was conducted with Administrator and copy of report was discussed and provided.the state’s words, verbatim · CDSS document, Mar 25, 2026 · control 22-AS-20221102163155

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Khatera Bahadory and discussed the purpose of the visit. The facility is a two story building with seventy three resident bedrooms, three staff offices, two laundry rooms, two court yards, a medication room, dinning room, TV lounge, and kitchen. The facility appears clean, safe and sanitary. All resident bedrooms have the required components and furnishings. LPA observed resident bathrooms to have toilet paper, grab bars, paper towels and nonslip mats in the shower. LPA tested the water to be between 109.4-118.4 degrees Fahrenheit. LPA observed the laundry room on the first floor to be locked and made inaccessible when not in use. LPA observed the first floor medications cart and the memory care unit medications cart to be on the first floor and locked making them inaccessible to residents in care. LPA observed the laundry room on the second floor to be unlocked for assisted living residents to use. LPA observed the medication room to be on the second floor with medication carts locked and made inaccessible to residents in care. LPA observed the first aid kit to be in the medication room and has all the required components. LPA observed the memory unit doors to have operational delayed egress. LPA observed the kitchen to be clean and free of vermin. LPA observed a two day perishable and seven day nonperishable food supply on hand. LPA observed fire extinguishers in the kitchen and throughout the facility charged and with a service date of August 6, 2025. LPA observed the toxins and chemicals to be on the housekeeping carts and locked in the maintenance room behind the facility and made inaccessible to residents in care. LPA observed activities being conducted in the dining room during the inspection with residents. Continue on LIC 809-C LPA observed two shaded seating areas outside for resident use that can be accessed through the memory care unit and the assisted living unit. LPA observed the emergency food and water supply to be stored in a shed in the memory care unit courtyard. LPA observed the outdoor areas to be free of debris and obstructions. LPA observed a fire inspection report from Thunder Fire Protection that was conducted on December 4, 2025 stating the facility fire alarms and smoke detectors were operational. LPA observed the last fire drill was conducted on December 12, 2025. LPA observed staff files and no discrepancies were observed. LPA reviewed resident files and no discrepancies were observed. LPA reviewed resident medications and no discrepancies were observed. Based on todays observations, no deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 11, 2026

Allegation investigated: Staff did not keep facility free of insects.

On February 4, 2026, Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of initiating the complaint investigation into the above allegation. LPA was greeted by the receptionist and was introduced to Wellness Director (WD) Adriana Delgado. Administrator (Admin) arrived approximately 10am and remained at the faciltity to assist with obtaining records. During the course of the investigation, LPA toured the facility guided by WD Delgado and inspected the kitchen and ten units consisting of three memory care units on the first floor, two assisted living units on the 1st floor, and five assisted living units on the second floor. LPA interviewed ten residents, four staff, and obtained copies of the following records for review: Resident Roster, Personnel Report Summary, Face Sheets, Physician's Reports, and Pest Control Service Reports. The investigation is as follows: Regarding the allegaiton, Staff did not keep facility free of insects, it is alleged that a cockroach was observed on January 30, 2026. Based on the inspection of ten units, no cockroaches were observed in the units, bathrooms, and furniture. Unsubstantiated LPA did not observe any cockroaches in the hallway. LPA observed the housekeeping staff on shift and cleaning each unit and common areas. Two out of ten residents confirmed seeing cockroaches in the hallways and in their rooms while four out of four staff denied observing and receiving reports of cockroaches from residents. Four out of four staff confirmed that the facility receives monthly pest control services or as needed. In review of the pest control service reports, LPA confirmed the pest control services the facility on a monthly basis. The service reports dated November 25, 2025, December 29, 2025, and January 30, 2026, documents no signs of cockroach activity per the inspections or observed by staff. The investigation revealed that although two of ten residents confirmed observing cockroaches, there were no signs of activity in the ten units, hallway, and kitchen per LPA's inspection which was also confirmed on the service reports. It is determined that facility is actively addressing the issue by implementing proactive measures and utilizing professional pest control services. Therefore, due to conflicting information, the allegation is deemed UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Administrator Khatera Bahadory, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 22-AS-20260130160632

Allegation investigated: Staff inappropriately communicate with resident

On December 30, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Assistant Administrator (AA) Kathleen Tamondong was notified via telephone and later arrived to assist with the inspection. On today's visit, LPA, accompanied by the AA, conducted a tour of the physical plant of the facility. LPA observed the facility to be clear of any obstructions or hazards. LPA conducted six resident interviews and five staff interviews. LPA also collected pertinent documents to the complaint such as the current resident roster, the current staff roster, and resident records. Regarding the allegation that, staff inappropriately communicate with resident, the following has been concluded: CONTINUED ON LIC9099-C Substantiated It was alleged that a facility staff spoke inappropriately to R1 after she sustained her unwitnessed fall. LPA conducted an interview with R1 who confirmed the allegation and stated that a facility staff insulted her after she sustained her unwitnessed fall. LPA conducted an additional five resident interviews regarding their experience with facility staff. Two out of the five residents interviewed stated that a facility staff has also spoken to them in an inappropriate manner such as with rude or mean comments. However, three of out of five residents interviewed denied staff ever speaking to them in an inappropriate manner and stated that they believe staff are friendly. LPA also conducted five staff interviews. Two out of the five staff interviewed denied the allegation and stated that they have never witnessed or heard of staff speaking to a resident in an inappropriate manner. However, three out of the five staff interviewed confirmed the allegation. The three staff stated that they are aware of previous incidents in which a staff has spoken to a resident in an inappropriate manner. Additionally, two of the staff interviewed stated that they have personally witnessed a staff speak inappropriately to a resident. LPA conducted a total of eleven interviews for this complaint, including interviews with residents and staff. Out of the eleven people interviewed, six people corroborated the complaint allegation. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, staff inappropriately communicate with resident. The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted with Assistant Administrator Kathleen Tamondong. A copy of the report and Appeal Rights were provided. It was alleged that facility staff did not attend to Resident #1 (R1) in a timely manner after she sustained an unwitnessed fall on an unknown date. LPA reviewed the facility's charting notes and observed that R1 had a documented fall at the facility on November 24, 2025, at approximately 3:50 AM. 9-1-1 was called and R1 was transported to the hospital. LPA conducted an interview with R1. R1 said that she had rolled out of her bed and that she was on the floor for approximately one hour before a facility staff found her. R1 said that because of her condition, she was unable to pull the call cord in her bedroom that would have alerted staff. LPA conducted an interview with R1's roommate, Resident #2 (R2). However, R2 was unable to provide any information on how long R1 might have been on the floor before she was assisted by a facility staff. LPA conducted five staff interviews. Two out of the five staff interviewed were unable to provide any useful information for the complaint allegation. Three out of the five staff interviewed denied the allegation and stated that R1 was assisted in a timely manner after she sustained her unwitnessed fall. LPA conducted an additional three resident interviews. Three out of the three resident interviewed stated that staff have always helped them in a timely manner. Due to conflicting information gathered during this investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Assistant Administrator Kathleen Tamondong and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 22-AS-20251224103733

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 30, 2026

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not evidenced by: Based on a total of eleven interviews conducted with both residents and staff, the Licensee did not ensure that resident's are spoken appropriately to by staff. This poses a potential health, safety, and personal rights risk, to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: The Assistant Administrator stated that they will conduct an in-service training with all facility staff regarding the personal rights of residents. The Assistant Administrator agreed to provide LPA proof of training via email or fax by POC date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit to amend Complaint Control Number 22-AS-20250701132137. Upon arrival, LPA Haddadin met with assistant AD Kathleen Tamondong, who granted entry to the facility. LPA explained the purpose of the visit. An exit interview was conducted with AD. At the conclusion of the visit, LPA Haddadin provided copies of all reports to assistant AD Kathleen Tamondong.the state’s words, verbatim · CDSS document, Dec 29, 2025

Allegation investigated: Facility failed to issue proper notification for rate increase

{***This is an Amended***} On July 15, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint investigation at the facility. Upon arrival, LPA Haddadin was greeted by Khatera Bahadory AD, who granted entry and was advised of the purpose of the visit. During the investigation, the analyst toured the premises, residents and staff and reviewed all facility records concerning the allegation. The allegation under review stated that the facility failed to issue proper notification for a rate increase. The investigation revealed that on March 31, 2025, the facility provided R1 with a 60-day written notice of a rate increase, scheduled to take effect on May 31, 2025. During an interview with the LPA, Resident 1 (R1) confirmed receipt of the notice. Effective January 1, 2025, Residential Care Facility’s for the Elderly are required to provide residents a 90 days written notice of increasing rates of fees, or increasing any of its rate structures for services, to residents or their representatives. The written notice must include the amount of the increase, the reason or reasons for the increase, and a description of the additional costs, except for an increase in the rate due to a change in the level of care of the residents. Per 60 day written notice of rate increase provided to R1, rate increase was based off the facility raising their rate for basic services, no description of the additional costs was provided. Per R1’s Admission Agreement, R1 did not stipulate their source of income, meaning if their source of income was based on private pay and/or Social Security Income SSI). Therefore, the facility could not be expected to adhere to SSI payment standards for R1. Although the facility had the right to increase R1’s rate, the notice provided to R1 failed to meet 90 days written notice requirement. Therefore, based on observations, interviews, and the information gathered during the investigation, the preponderance of the evidence standard has been met. Therefore, the allegation that the Facility failed to issue proper notification for rate increase is deemed Substantiated. The following is being cited per California Code of Regulations Title 22 1569.655(a). An exit interview was conducted, and a copy of this report, Appeal Rights and Confidential Names List was provided to the Administrator. *****AMENDED***** Substantiatedthe state’s words, verbatim · CDSS document, Dec 24, 2025 · control 22-AS-20250701132137

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.655(a) · Plan of correction due date: Jan 14, 2026

1569.655(a)If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents Based on record review, licensee failed to ensure R1 was given a 90 day notice This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 24, 2025

Plan of correction: Licensee will refund any money owed to R! and send proof of such to LPA by POC due date

Type of visit: Case Management - Other

On the above noted date and time, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit to Amend a prior complaint. The complaint control number amended was 22-AS-20250701132137. Upon arrival, LPA Haddadin was greeted by Khatera Bahadory AD, who granted entry and was advised of the purpose of the visit An exit interview was conducted and a copy of this report and amended complaint reports were provided to AD.the state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Facility did not refund resident their money

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Khatera Bahadory, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that facility did not refund resident their money revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD and residents, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Admission Agreement, and R1’s Billing Statement. CONTINUED Substantiated It was alleged that R1 was overcharged and not refunded by $22.58 in fees for basic services. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA reviewed R1’s Admission Agreement which indicates R1 moved in on August 15, 2022, R1’s monthly rate for basic services was $1,400, and that prorating of the monthly rate is based on a 30-day month. R1 stated that when they moved in, their $1,400 fee should have been prorated to $700 based on 15 days between August 15 through August 30, 2022 based on the Admission Agreement’s 30-day month prorate rule, but instead their $1,400 fee was prorated to $722.58 based on 16 days between August 15 and through August 31, 2022. LPA reviewed a calendar which confirmed that August 2022 had 31 days in it. Based on the Admission Agreement, R1 was overcharged by $22.58 in August 2022. However, R1 never told the facility about this issue and AD denied ever being notified about this billing issue but was unable to provide documentation regarding how much R1 paid in August 2022. Per AD, R1 is back paid on their monthly fees in the amount of $2,500 and has been back paid on their monthly fees since June 2025. LPA reviewed R1’s Billing Statement which shows that R1 has been back paid on their monthly fees since June 2025 and has a current outstanding balance. While R1 is not entitled to a refund because they have an outstanding balance, they are entitled to a credit of $22.58 on their outstanding balance because the facility made a billing error based on the prorating provision of the Admission Agreement. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 22-AS-20250716163949

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jul 28, 2025

87507 Admission Agreements … (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not follow its admission agreement when it overbilled R1 by $22.58, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2025

Plan of correction: Licensee stated they will credit R1 by $22.58 and submit proof to LPA by POC due date.

Allegation investigated: Facility failed to provide an appropriate bed.

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of investigating the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Khatera Bahadory and discussed the purpose of the visit. The investigation into the allegation Facility failed to provide an appropriate bed revealed the following: LPA observed two pictures that were taken of box springs and mattresses stacked on top of each other with no bedding. LPA observed the resident census list with the shared room occupancies. The room where the mattresses were observed to be stacked has only one resident in care at this time. LPA observed a shared bedroom with one bed unoccupied and not currently being used by any residents. The unused bed was observed to have a bedframe and a box spring. LPA observed the single occupant residing in the room to have a bed, bedframe, box spring and clean linens. LPA observed other resident rooms to have beds, bedframes, linens and box springs throughout the facility. LPA observed an email sent by the AD informing the Department of the renovations on July 9, 2025. Continue on 9099-C Unfounded LPA observed the resident census list with the shared room occupancies. The room where the mattresses were seen stacked has only one resident in care at this time. LPA observed a shared bedroom with one bed unoccupied and not being used. LPA observed a bed frame and box spring. LPA did not observe a mattress with an odor. Based on information gathered during the investigation the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred: therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with AD Khatera Bahadory and a copy of this report was left at the facility. Upon interviews with Resident #1 (R1) it was revealed that the facility staff stacked the mattresses there for a short time while they were moving residents from the first floor to the second floor due to the construction that was taking place on the first level. R1 did not recall how long the mattresses and box springs were there but stated that they were not there for a long time and have since been removed. R1 informed LPA that no one slept on the stacked mattresses while they were in the room. Upon interviews with 2 of 2 staff revealed that they placed the mattresses and box springs in the room due to needing space while moving residents from the first floor to the second floor temporarily due to the construction that would be taking place. 2 of 2 staff informed LPA that the mattresses and box springs were removed out of the resident’s room and were not stored there. AD informed LPA that since they have been working at the facility, the bed in the room where the stacked mattresses were observed has remained unoccupied with no residents using the stacked beds. LPA observed AD's personnel record that states they started working at the facility on April 1, 2025. Based on observation, interviews and information gathered during the investigation the preponderance of evidence standard has not been met, therefore the above allegation is deemed UNFOUNDED. Meaning the allegation Facility failed to provide an appropriate bed was false, could not have happened and/or is without a reasonable basis. The department therefore dismissed the complaint. An exit interview was conducted with AD Khatera Bahadory and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 18, 2025 · control 22-AS-20250709151002

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of conducting a case management deficiencies visit. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Khatera Bahadory and discussed the purpose of the visit. The department received a cross report from OC Public Health stating that there was a COVID outbreak at the facility. The outbreak infected 8 out of 107 residents in care. No staff were reported to having COVID during this outbreak. The facility continued to test for additional cases two times a week. The last known case was identified on June 25, 2025. No additional cases were noted as July 8, 2025. LPA observed an email reporting the COVID cases on June 27th, 2025 to OC Public Health. LPA did not observe a report being sent to the Orange County Regional Office regarding the same cases. Based on today’s visit a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Khatera Bahadory and a copy of this report along with appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Aug 8, 2025

Reporting Requirements 87211(a)(2) Occurrences, such as epidemic outbreaks... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone... to the licensing agency... This requirement is not met as evidence by: Licensee did not ensure to report the COVID occurrences to the licensing agency. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: Administrator stated they will do an in-service with staff and provide a signed statement of understanding to LPA by POC due date.

Allegation investigated: Facility failed to issue proper notification for rate increase

On July 15, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint investigation at the facility. Upon arrival, LPA Haddadin was greeted by Khatera Bahadory AD, who granted entry and was advised of the purpose of the visit. During the investigation, the analyst toured the premises, residents and staff and reviewed all pertinent facility records concerning the allegation The allegation under review stated that the facility failed to issue proper notification for a rate increase. The investigation revealed that on March 31, 2025, the facility provided R1 with a proper 60-day written notice of a rate increase, scheduled to take effect on June 1, 2025. During an interview with the LPA, R1 confirmed receipt of the notice. Based on observations, interviews, and the information gathered during the investigation, the preponderance of the evidence standard has not been met. Therefore, the allegation that the facility issued an unlawful eviction is deemed UNFOUNDED. An unfounded allegation means the evidence indicates the charge is false, could not have happened, or is without a reasonable basis. Accordingly, the department has dismissed the complaint. An exit interview was conducted, and a copy of this report was provided to the Administrator. *****AMENDED***** Unfoundedthe state’s words, verbatim · CDSS document, Jul 15, 2025 · control 22-AS-20250701132137

Allegation investigated: Staff do not ensure residents receive their mail correspondence unopened in a timely manner

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPA Rodriguez explained the purpose of today's visit, and was greeted by facility administrator (AD) Khatera Bahadory. During the investigation, LPA Rodriguez toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that staff do not ensure residents receive their mail correspondence unopened in a timely manner. LPA Rodriguez conducted a total of 8 resident interviews of which all 8 interviews did not corroborate with the allegation. LPA Rodriguez conducted a total of 2 staff interviews of which the 2 interviews did not corroborate with the allegation. Unfounded Per interviews, it was stated that the facility has a designated area located at the reception desk, where each resident has their own folder and that the receptionist will organize the mail and place mail in the corresponding resident folder. All resident and staff interviews also revealed that the facility will announce via intercom when mail has arrived to alert residents to retrieve their mail. During the tour of the facility, LPA Rodriguez observed the mail folders of residents and observed that all mail and packages were unopened and sealed. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, this allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with AD Bahadory. A copy of this report was explained and provided.the state’s words, verbatim · CDSS document, Jun 9, 2025 · control 22-AS-20250606151149

Allegation investigated: - Staff are not giving resident's belongings to resident after resident left the facility

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conduct a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Assistant Administrator (AA) Kathleen Tamondong and (ED) Khatera Bahadory arrived shortly to assist with the visit. The department received a complaint on May 15, 2025 and LPA Tea conducted the initial 10 day visit a week later on May 21, 2025. It was alleged that facility staff are not giving resident’s belonging to resident after resident left the facility. LPA Tea interviewed facility staff and collected pertinent documents such as staff and resident rosters, copies of Resident 1 (R1)’s file. The investigation determined the following: Report continued on LIC9099-C Unfounded Per review of admission agreement, “Belongings Removal” section, In the event of a resident’s death or any way vacating of premises, facility will make responsible efforts to assist resident and/or responsible person with belonging removal. Facility requires all resident personal belongings to be removed within five days. Also, in the admission agreement the facility is not responsible for storing resident belongings. R1 has left the facility since April 30, 2025 to a new facility, and R1’s belongings has been here for almost a month, well past five days. The facility has been gracious to keep R1's belongings past the grace period. Per interviews with assistant administrator and Executive Director, the facility has never withheld R1’s belongings. R1 and their responsible party can pick up R1’s belongings anytime. The facility has also said they do not have contracts, promissory notes to arrange or pay for arrangements for belongings to be moved, it’s the sole responsibility of the resident or responsible party to move their belongings. Assistant Administrator and Executive Director said they have not touch R1’s belongings and left it the way R1 left it when they moved to the other facility. Based on LPA’s observations, LPA Tea toured R1’s former room and notice a closet full of miscellaneous items and several big plastic tubs and a lot of personal grooming items and fast-food drink cups on top of the facility dresser. All items are left untouched. R1 had also left a refrigerator. The facility hopes R1 and responsible party would pick up the items so they can have a bed available for a future resident. Out of respect for R1 they do not touch or move the items or throw it out. AA Tamongdong has said the facility has offered help to organize R1’s belongings. ED Bahadory also noted that when the other facility came to pick up R1, they said they would come back and pick up the rest of R1’s belongings. The facility has called and left several messages for R1’s primary responsible party and emailed. There has never been a response from them. Facility provided copies of emails sent to the responsible party of R1 prior and after R1 moving regarding facility placement and what to do with R1’s belonging. LPA did try to reach out R1’s primary responsible party and did not get any response as well. LPA did spoke to R1’s other brother who is not the primary responsible party and admitted that it was hard to get a hold or responses from the primary responsible party. And their other brother who lives in California does not have space permitted for R1’s belongings. They will try to reach out to R1 to see if they can arrange something or a possible solution. Report continued on LIC9099-C Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegation that facility staff are not giving resident’s belonging to resident after resident left the facility has been determined as UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited at this time and an exit interview was conducted with Executive Director Khatera Bahadory and Assistant Administrator Kathleen Tamondong. A copy of the report and confidential names list was provided to the facility.the state’s words, verbatim · CDSS document, May 21, 2025 · control 22-AS-20250515082023

Allegation investigated: Facility staff does not administer medications as prescribed

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as medication administration record. Regarding the allegation that facility staff does not administer medications as prescribed, the investigation revealed the following: Per physician report dated 02/10/2025, Resident 1 (R1) is able to administer own medications and injections. Resident is diagnosed with Type 1 Diabetes and is prescribed insulin. Per medication administration record, R1 is administering own medications. Based on record review, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative. Unfounded Facility staff indicated not being aware of any concerns regarding the smoking area. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the following allegations are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 22-AS-20250227101758

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(4) · Plan of correction due date: Apr 23, 2025

The licensee shall be permitted to accept or retain a resident who has diabetes..... In addition,, the licensee shall be responsible for the following: Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This req is not met Based on record review and interview, Licensee failed to ensure R1 was provided a physician prescribed diabetic diet. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: Licensee to provide an inservice on prescribed meals and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 23, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This req is not met as evidenced by: Based on observation, Licensee failed to ensure facility was in good repair. LPA observed a non-operational telephone on the second floor. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: Licensee to repair/ replace telephone and forward proof to LPA by POC due date.

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Administrator Assistant Kathleen Tamondong. LPA explained the reason for the visit. Administrator Ellen Barrientos arrived during the visit. This agency has investigated the complaint alleging that Resident received an unlawful eviction. Regarding the allegation, the following was revealed: During the course of the interviews one of six individuals interviewed confirmed the allegation. During the course of the investigation LPA reviewed documents including the Palms Retirement Center Admission Agreement dated August 15, 2022 for Resident 1 (R1). Per Admission Agreement for R1 under Rate for Basic Services it states all charges for basic and optional services are subject to change upon 60 days written notice. LPA reviewed documents including the Palms Retirement Center new rent rate change dated November 25, 2024 for R1. Per new rent rate change letter on CONTINUED ON LIC9099-C... Substantiated January 01, 2025 the new rent rate will change from $1540.00 to $2,500. During the investigation LPA reviewed the Palms Retirement Center Eviction notice dated February 28, 2025 for R1. Per Eviction notice R1 was issued an Eviction for failure of the resident/s to pay agreed upon rate of basic services within 10 days of due date. Per Health and Safety Code section 1569.655 under section (a) it states that if a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs. Based on observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the following allegation: Resident received an unlawful eviction is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 22-AS-20250318082211

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(1) · Plan of correction due date: Apr 3, 2025

Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...(1) Nonpayment of the rate for basic services within ten days of the due date. This requirement was not met as evidence by: The Licensee issued R1 a 37 days written notice for new rent rate change instead of no less than 60 days'. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Licensee agreed to issue a 60 day notice new rent rate increase and a new Eviction notice for R1. Licensee to email the POC to LPA by POC due date.

Allegation investigated: Staff are mismanaging residents medication Staff did not ensure resident was seen by their own physician

On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannoucned visit to conduct a complaint investigation.LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on 03/20/2025 and the initial 10 day visit was conducted on 03/26/2025. During the visit LPA Mendivil interviewed staff and residents. LPA Mendivil obtained copies of physician report, needs and services, preapprasial, admission agreement. Regarding the allegations staff are mismanging residents medication and staff did not ensure resident was seen by their own physician, the invesitgation revealed the following: It was alleged the facility was mismanaging residents' medication. Per interviews with 6 out of 6 residents stated the facility provides their medications as prescribed. Per interviews with 4 out of 4 staff indicated they provide all resident medications as prescribed. Unsubstantiated 4 out of 4 staff stated if the resident refuses the medication they will notate the refusal in the resident's chart. Interviews with staff indicated if a resident has a pattern of refusals they notify the resident's physician. Interviews also indicated staff would advise residents' of the side effects of refusals of certain medications. Staff stated they understand residents have the right to refuse medications and they honor that right. 6 out of 6 residents stated they are able to see a doctor of their choosing based on their own insurance. Facility manager stated they allow residents to choose their own physician based on their insurance. 4 out of 4 staff denied the allegation that facility is not allowing residents to see a physician of their own choosing. Therefore based on the preponderance of evidence through interviews and records reviewed the allegations staff are mismanaging residents medication and staff did not ensure resident was seen by their own physician are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited at this time and an exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 22-AS-20250320123519

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Nancy Guillen and Ruth Martinez made an unannounced visit for the purpose of conducting a required annual Inspection. LPAs were greeted and granted entry by Facility Manager, John Garcia, after explaining the purpose of the visit. Administrator (AD) Eleanor P. Barrientos’s certificate was current and expires June 17, 2025. This is a Residential Care Facility for the Elderly (RCFE) licensed to one hundred forty-four non-ambulatory residents, of which thirty two may be bedridden, with a hospice waiver for ten. The facility is made up of two floors with seventy three resident bedrooms, two staff offices, two laundry rooms, two court yards, a Med room, dinning room, TV lounge, library, balcony, and kitchen. During the inspection, LPAs, Facility Manager,and Administrator Assistant conducted a tour of the inside and outside of the facility and observed the following: LPAs observed the See Something Say Something Poster (PUB 475) mounted on the wall by the facility entrance. LPA Guillen began inspection of resident rooms. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the linen closet on the second floor. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105 and 114 degrees Fahrenheit. LPA Martinez toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the outdoor court yards had a shaded seating area with furniture for resident use. LIC-809C LPA Martinez observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide system was checked by Code Red Fire Inc on November 18, 2024 and inspection passed. Sprinkler system was inspected by State Fire Marshall on August 20,2024 and system passed. Egress doors were reportedly tested on February 17, 2025 and were tested throughout the facility by LPA. Fire extinguishers were mounted and located throughout the facility, fully charged with a service date of August 22, 2024. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked and inaccessible to residents in maintenance storage behind the building. Medication and First Aid kit was observed to be locked and centrally stored in the Med Room. First Aid Kit had all the required components. LPA Martinez observed the facility conducted their last emergency disaster drill on February 5, 2025 and is conducted monthly. LPA Martinez began review of the records. LPA reviewed eleven resident records. All the required documentation were present and current in the residents’ files reviewed. LPA reviewed nine employee records. All employee’s present have a criminal record clearance and were associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 3, 2025

Allegation investigated: - Facility staff is not acting to prevent a bed bug infestation

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conduct a complaint investigation. LPA Tea was greeted and granted entry into the facility by Assistant Administrator (AA) Kathleen Tamondong and explained the reason for the visit. Administrator (AD) Eleanor Barrientos arrived later to assist with the visit. The department received a complaint on February 14, 2025 and LPA Tea conducted the initial 10 day visit a week later on February 21, 2025. It was alleged that facility staff is not acting to prevent a bed bug infestation. LPA Tea interviewed facility staff and residents and collected pertinent documents such as staff and resident rosters, copies of Resident 1 (R1)’s file, and pest control maintenance paperwork and log. The investigation determined the following: Report continued on LIC9099-C Unsubstantiated Per review of pest control maintenance paperwork and service logbook, facility currently has no bed bugs as shown in a recent service report from the facility’s pest maintenance company dated February 20, 2025. AA Tamondong said that pest control comes to inspect the facility quarterly and as needed. However there was a bed bug infestation reported on December 19, 2024 in which the facility was treated for. The following service report on January 2, 2025 shows that there are no evidence of bed bugs in the facility since December. Six out six staff interviewed said that there are no bed bugs currently and they react right away to contain and treat any infestation of bed bugs. All staff interviewed noted the facility check the rooms, gather clothes and bedding and wash and treat them. Afterwards facility maintenance staff clean and spray chemicals to treat for bed bugs. Then pest control comes out for prevention and maintenance. Per interviews, eight out twelve residents agree that the facility was doing a good job in preventing and acting upon bed bug infestations and pests. LPA Tea interviewed Resident 1 (R1) who felt there was no urgency or quick action when addressing a possible bed bug infestation. R1 said they felt itchy and the bites felt like goosebumps or “chill bumps.” R1 said the facility was slow to respond and check their room. While interviewing R1, LPA Tea was making observations and saw no visible bite marks on R1. LPA Tea inspected R1 and their roommate’s bed and the areas around and observed no bed bugs at the time. Per interviews, two out of two maintenance staff who checked R1’s room confirmed there were no bed bugs in the room. Maintenance staff checked and treated R1’s room upon report of possible bed bugs. AA Tamondong noted that pest control will do another inspection on February 24, 2025. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegation that facility staff is not acting to prevent a bed bug infestation has been determined to be unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited at this time and an exit interview was conducted with Administrator Eleanor Barrientos and Assistant Administrator Kathleen Tamondong. A copy of the report and confidential names list was provided to the facility.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 22-AS-20250214164901

Allegation investigated: Facility staff are mismanaging residents' medication

An unannounced Complaint Investigation was conducted on this day regarding the allegation mentioned above by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Interim Administrator John Garcia and Assistant Administrator Kathleen Tamondong During the course of the investigation, LPA reviewed Medication Administrator Records (MARs) for ten residents and interviewed staff. LPA observed discrepancies in five of ten records. Resident 1’s (R1’s) MAR indicated five routine medications are not currently being administered, and one of the five medications is completely out, and has been without a refill for three days. During today’s inspection, two of four PRN medication for R2 were observed to be without a refill. During review of R2’s medication, during initial complaint investigation conducted on January 28, 2025, three of four PRN medications were observed to be without a refill. Per R3’s MAR, routine medication was not administered on the morning of January 24th and 27th 2025, and the evening of January 25th and 26th, 2025 as it was not signed by staff to indicate it was administered or otherwise. (LIC9099-C) Substantiated During their interview, Staff 1 (S1) stated medication had not been administered due to R3 being in the hospital. Upon review of R3’s medication, medication was observed to no longer be in the prescription bubble pack issued by the pharmacy. Upon medication review for R4, LPA observed routine medication was not administered on January 12, 2025, nor on January 19, 2025. R4’s MAR was left blank on January 12, 2025, but was signed off by staff on January 19, 2025, despite medication having not been administered and observed to still be inside the prescription bubble pack issued by the pharmacy. Per R5’s MAR, two routine medications were not administered on January 27, 2025 and five of seven PRN medications were not observed. During their interview, S2 stated medication has been administered and signature had been overlooked by staff. During their interview, S1 indicated five of the seven PRNs for R5 were currently awaiting refill and not available for review. Based on staff interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. A deficiency is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided at the end today's inspection.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 22-AS-20250121122441

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Jan 30, 2025

"Care and supervision" means the facility assumes responsibility for... ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety or welfare would be endangered. This requirement is not met as evidenced by: Based on staff interviews and records review, the licensee did not comply with the section cited above as residents' medication is being mismangaged, which poses an immiedate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: IAD stated residents' MARs will be updated to reflect correct information regarding medication administration and medication staff training conducted. IAD stated they will provide LPA with proof via email by POC date.

Type of visit: Required - 1 Year

On 5/8/2024, Licensing Program Analyst’s (LPA’s) Jenifer Tirre, Kimberly Lyman and Edward Kim conducted an unannounced required visit using the CARE Inspection Tool. LPA’s were greeted by staff and granted entry after stating the purpose of the visit. Administrator (Admin) Erin Rehbein was present to assist with the facility inspection on today's date. The facility is licensed for (144) non-ambulatory residents with approved hospice waiver for ten (10) residents. Currently, there are three (3) Hospice residents present during today’s visit. At around 9:00am , LPA’s conducted a tour of the physical plant accompanied by Administrator Erin Rebehin, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. LPA’s observed one bedroom room 119 to have missing smoke detector. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 105.1 to 117.6 degrees F. A comfortable temperature of 76 degrees F. was maintained in the facility. LPA’s observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. During visit five fire extinguishers were observed as fully charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA’s observed the records are in compliance. A review of staff and resident records were reviewed and observed to be out of compliance. CONTINUED ON 809C During the visit, LPA's observed the facility's infection control practices. LPA's observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA's observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA’s observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 4/4/24. The facility provided documentation from Cal Fire which confirmed operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 8/1/2023- 8/1/2024. A review of ten residents (R1-R10) service files was revealed to be complete. Ten staff files were reviewed (S1-S10) and ten out of ten personnel files revealed to be incomplete in area training. Based on the observations made during today's visit, deficiencies are being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator.the state’s words, verbatim · CDSS document, May 8, 2024

Allegation investigated: Facility is refusing to accept the resident back to the facility

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and resident as well as reviewed and obtained pertinent documentation such as hospital discharge paperwork. Regarding the allegation that facility is refusing to accept the resident back to the facility, the investigation revealed the following: Resident 1 (R1) was sent out to to Chapman Global Medical Center on 03/15/2024 to be evaluated per physician. On 03/25/2024, Administrator assessed the resident and was concerned the resident was not ready to be released back to the facility due to ongoing behavioral issues. However, Administrator stated receiving the resident back into the facility on 03/26/2024 and accepted the hospital's discharge assessment. Administrator denies refusing to take the resident back to the facility but confirms requesting additional treatment time from hospital for the resident. Resident confirms hospitalization as well as a return to the facility with no issues returning. Hospital discharge CONT ON LIC 9099C DATED 04/03/2024 Unsubstantiated paperwork confirms resident was discharged back to facility on 03/26/2024. Based on interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Apr 3, 2024 · control 22-AS-20240325145159

Type of visit: Case Management - Incident

On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit to follow up on an Incident that occurred on March 14, 2024. LPA discussed purpose of visit with Administrator Erin Rehbein. On March 19, 2024 Department received a Self reported SOC 341 Report from Facility. Facility reported that an incident occurred between two residents on March 14, 2024. Staff reported to Administrator that in passing in facility hallway, Resident 1 (R1) approached Resident 2 (R2). Staff reported that R2 was rubbed by R1 on the right side thigh and butt area. Staff also reported that same incident occurred a second time on March 16, 2024. Upon learning of incident Administrator had staff member (S1) translate to R2 regarding incident. Based on translation S1 stated that they asked R2 if they were touched inappropriately to which R2 shook their head "no". S1 asked R2 if they were hurt and R2 stated "Ok" in Vietnamese. Based off interviews with staff, Administrator stated that they spoke to R1 regarding incident and R1 claimed they "did not know anything". Facility had sent out R1 to hospital for Psych Evaluation. R1's face sheet, Appraisal, and Emergency info all state that R1 has a health history of Dementia and Schizophrenia. R1's Physician's Report dated November 30, 2023 has diagnosis of Pneumonia, COPD and mild cognitive impairment. At time of visit R1 not present for interview. R1 has not returned to facility. Administrator states upon R1's discharge they plan to work with conservator regarding plan of care moving forward. During visit, with the help of staff 1, LPA attempted interviewing R2 regarding incident, upon attempt R2 nodded head "yes" when asked if they were okay. R2 was asked if they had been touched and R2 nodded "no". R2 was unable to verbally communicate due to a language barrier. LPA observed R2's Physician Report which has Schizophrenia listed as primary diagnosis and lists Cerebral Infarction as secondary diagnosis. R2's Resident's Appraisal dated 11/30/23 states R2 has a communication deficit and unable to communicate needs clearly. CONTINUED ON 809C Administrator contacted responsible parties, Licensing, Ombudsman and Police regarding incident. LPA received copies of resident physician's reports and appraisals. An exit interview was conducted with Assistant Administrator Kathleen Tamondong and a copy of report was left at facility.the state’s words, verbatim · CDSS document, Mar 19, 2024

Allegation investigated: Staff did not provide adequate notice of rate change

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and resident as well as reviewed and obtained pertinent documentation such as rate increase letter. Regarding the allegation that staff did not provide adequate notice of rate change, the investigation revealed the following: Facility staff indicate scanning a notice of rate change to Resident 1's (R1) responsible party on 11/20/2023 after receiving notification from Community Care Licensing of the SS1 rate change. Facility mailed an additional copy on 12/15/2023 for signature. Responsible party stated not receiving the first notice and receiving the second notice on 12/28/2023. Facility staff stated scanning the first notice directly from facility scanner and not from email. Facility staff indicated no way to access a receipt or dated proof of scan. Administrator reached out to tech support for guidance on how to access a scan receipt. Tech support indicated no receipt or time stamp is available. CONTINUED ON LIC 9099C DATED 02/08/2024. Unsubstantiated Based on interviews conducted and record review, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 22-AS-20240201121336

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20240201121336. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the complaint investigation, LPA interviewed witness and staff. Resident 1 (R1) was admitted at a skilled nursing facility in December 2023 and returned to the facility February 3, 2024. During the resident's absence, resident's belongings were moved to storage and then changed from room 213 to room 212. Facility staff as well as witness indicate there was no notice provided for the room change. . Based on the observations made from today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.the state’s words, verbatim · CDSS document, Feb 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(16) · Plan of correction due date: Feb 22, 2024

...residents in privately owned facilities for the elderly shall have all of the following personal rights: To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency. This req is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure R1 was given a 30 day notice for room change. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Licensee to submit a statement of understanding of the regulation to LPA by POC due date.

Type of visit: Collateral

On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit for the purpose of conducting a collateral visit in regards to an open complaint investigation unrelated to current licensee. LPA met with Administrator Erin Rehbein and explained reason for the visit On this day LPA conducted interviews related to complaint control number: 22-AS-20200925103558 During visit LPA conducted additional interviews and gathered records related with the following open complaints for Palms Retirement Center: 22-AS-20231009110307 22-AS-20230829083600 22-AS-20230802135409 22-AS-20230727154102 Exit interview conducted with Administrator and copy of report was provided to facility.the state’s words, verbatim · CDSS document, Oct 18, 2023

Allegation investigated: -Staff did not provide resident with facility rules and regulations in a timely manner -Facility has roaches

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews and deliver findings for complaint allegations listed above. LPA Quiroz was greeted by front desk receptionist and met with Administrator (AD Erin Rehbein and discussed purpose of today's visit. The 10 day visit was conducted on 6/05/2023 by LPA Quiroz. During the course of the investigation, LPA Quiroz conducted interviews with interviewees consisting of staff and residents. LPA Quiroz also conducted documentation review but not limited to resident roster, staff roster, Admission Agreements, Facility House Rules, Infection control Inservice records and Pest Control Invoices dated 3/09/2023, 3/23/2023, 4/20/2023 and 5/18/2023. Regarding the allegation " Staff did not provide resident with facility rules and regulations in a timely manner," the investigation revealed the following: Interview indicating “I did receive it, I had misplaced it, but I found it.” During documentation review of four of four resident's files, LPA Quiroz observed copy of facility house rules and Admission Agreements in four of four resident's files. CONTINUED ON NEXT LIC 9099-C PAGE... Unfounded CONTINUED...Four of four residents interviewed indicated receiving a copy of facility rules and regulations in a timely manner. Regarding the allegation "Facility has roaches," the investigation revealed the following: Seven of eight interviewees consisting of staff and residents denied the allegation indicating not observing any roaches in their bedroom and bathroom areas or through out the facility. Documentation review of Pest Control Invoices dated 3/09/2023, 3/23/2023, 4/20/2023 and 5/18/2023 indicated no pest found during the routinely monthly inspection maintenance visits. Therefore based on the preponderance of evidence gathered through interviews, observations conducted by LPA Quiroz and documentation review, the allegations that the "Staff did not provide resident with facility rules and regulations in a timely manner,” and “Facility has roaches,” are deemed UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. This agency has investigated this complaint. No deficiencies cited during today's visit. An exit interview was conducted with (AD) Rehbein and a copy of report was provided at exit.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 22-AS-20230530102018

Allegation investigated: -Staff are not following infectious control plan

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews and deliver findings for complaint allegations listed above. LPA Quiroz was greeted by front desk receptionish and met with Administrator (AD) Erin Rehbein and discussed purpose of today's visit. The 10 day visit was conducted on 6/05/2023 by LPA Quiroz. During the course of the investigation, LPA Quiroz conducted interviews with interviewees consisting of staff and residents. LPA Quiroz also conducted documentation review but not limited to resident roster, staff roster, physician reports, identification forms and Infection Control Inservice Material and Inservice logs dated 4/14/2023 and 6/5/2023. Regarding the allegation " Staff are not following infectious control plan,” the investigation revealed the following: Seven of eight interviewees consisting of residents and staff denied the allegation indicating staff are following infectious control plan as evidenced by conducting hand hygiene/washing, utilizing Protective Personal Equipment (PPE) for COVID-19 precautionary measures, cleaning and disinfecting re-usable medical equipment...CONTINUED ON NEXT LIC 9099-C PAGE... Unfounded CONTINUED...and handling blood and other potential infectious materials following all safety precautionary measures. During the facility inspection visits conducted on 6/5/2023 and on today’s date, LPA Quiroz observed facility staff working at the facility to be wearing pertinent Personal Protective Equipment (PPE), conducting hand hygiene, cleaning and disinfecting with use of gloves in appropriate settings as evidence by observing staff utilizing gloves when disinfecting bathroom areas, transporting trash, serving meals and while washing dirty linen and resident’s clothing items in laundry area. Therefore, based on the preponderance of evidence gathered through interviews, observations conducted by LPA Quiroz and documentation review, the allegations that the " Staff are not following infectious control plan” is deemed UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint. No deficiencies cited during today's visit. An exit interview was conducted with (AD) Erin Rehbein and a copy of report was provided at exit.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 22-AS-20230531092156